Abstract
Background
To the best of our knowledge, this is the first study to evaluate the predictive value of free air (on a plain radiograph) for bowel perforation in a large prospective cohort of surgical patients.
Methods
All consecutive patients undergoing abdominal surgery between January 2011 and June 2012 were screened for this study. We performed an upright chest radiograph on the second and third postoperative day. Thereafter, additional radiographic evaluations were performed every 2 days until the disappearance of abdominal free air.
Results
Of the 648 subjects enrolled in our study, free abdominal air was found in 65 subjects on the first radiographic evaluation (2 days after surgery), 51 on the second (3 days after surgery), three on the third (5 days after surgery), and none on the fourth (7 days after surgery). The presence of free abdominal air was associated with an increased risk of gastrointestinal perforation. The presence of free air was associated with a hazard ratio (HR) of 21.54 (95% CI 9.66–48.01, p<0.001) and a HR of 23.87 (95% CI 10.68–53.34, p<0.001) at 2 and 3 days after surgery, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value were 70, 93, 33, and 98%, respectively, at 2 days after surgery, and similar results were confirmed at 3 days after surgery.
Conclusion
We believe that the presence of free air at 3 days after surgery should not be considered a common finding. Here, we demonstrate that the detection of free air has a remarkable predictive value for gastrointestinal perforation, which has been overestimated in previous experience.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Tang CL, Yeong KY, Nyam DC, et al. Postoperative intra-abdominal free gas after open colorectal resection. Dis Colon Rectum. 2000 Aug;43(8):1116-20.
Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713-6.
Lee CH, Kim JH, Lee MR. Postoperative pneumoperitoneum: guilty or not guilty? J Korean Surg Soc. 2012 Apr;82(4):227-31.
Jackson SA, Laurence AS, Hill JC. Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia. 1996 May;51(5):485-7
Draper K, Jefson R, Jongeward R Jr, et al. Duration of postlaparoscopic pneumoperitoneum. Surg Endosc. 1997 Aug;11(8):809-11.
Feingold DL, Widmann WD, Calhoun SK, et al. Persistent post-laparoscopy pneumoperitoneum. Surg Endosc. 2003 Feb;17(2):296-9
Woodring JH, Heiser MJ. Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections. AJR Am J Roentgenol. 1995 Jul;165(1):45-7.
Kane NM, Francis IR, Burney RE, et al. Traumatic pneumoperitoneum. Implications of computed tomography diagnosis. Invest Radiol. 1991 Jun;26(6):574-8.
Lee FT Jr, Leahy-Gross KM, Hammond TG, et al. Pneumoperitoneum in peritoneal dialysis patients: significance of diagnosis by CT. J Comput Assist Tomogr. 1994 May¬Jun;18(3):439-42.
Miller RE, Nelson SW. The roentgenologic demonstration of tiny amounts of free intraperitoneal gas: experimental and clinical studies. Am J Roentgenol Radium Ther Nucl Med. 1971 Jul;112(3):574-85.
Paster SB, Brogdon BG. Roentgenographic diagnosis of pneumoperitoneum. JAMA. 1976 Mar 22;235(12):1264-7.
Ceydeli A, Fahoum B, Schein M. Delayed post-operative pneumoperitoneum. Dig Surg. 2002;19(5):420-2.
Harrison I, Litwer H, Gerwig WH Jr. Studies on the incidence and duration of postoperative pneumoperitoneum. Ann Surg. 1957 Apr;145(4):591-4.
Millitz K, Moote DJ, Sparrow RK, et al. Pneumoperitoneum after laparoscopic cholecystectomy: frequency and duration as seen on upright chest radiographs. AJR Am J Roentgenol. 1994 Oct;163(4):837-9.
Hope WW, Heniford BT, Norton HJ, et al. Duration and clinical significance of radiographically detected “free air” after laparoscopic nephrectomy. Surg Laparosc Endosc Percutan Tech. 2009 Oct;19(5):415-8.
Earls JP, Dachman AH, Colon E, et al. Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus radiography. AJR Am J Roentgenol. 1993 Oct;161(4):781-5.
Nielsen KT, Lund L, Larsen LP, et al. Duration of postoperative pneumoperitoneum. Eur J Surg. 1997 Jul;163(7):501-3.
Smith R, Kolyn D, Pymar H, et al. Ultrasonographic and radiologic evaluation of patients after laparoscopic cholecystectomy. Can J Surg. 1992 Feb;35(1):55-8.
Shatari T, Clark MA, Keighley MR. Duration of pneumoperitoneum on chest radiograph after open colorectal surgery. Tech Coloproctol. 2004 Mar;8(1):27-30.
Stanley IR, Laurence AS, Hill JC. Disappearance of intraperitoneal gas following gynaecological laparoscopy. Anaesthesia. 2002 Jan;57(1):57-61.
Schauer PR, Page CP, Ghiatas AA, et al. Incidence and significance of subdiaphragmatic air following laparoscopic cholecystectomy. Am Surg. 1997 Feb;63(2):132-6.
Bevan PG. Incidence of post-operative pneumoperitoneum and its significance. Br Med J. 1961 Sep 2;2(5252):605-9.
Gayer G, Jonas T, Apter S, et al. Postoperative pneumoperitoneum as detected by CT: prevalence, duration, and relevant factors affecting its possible significance. Abdom Imaging. 2000 May-Jun;25(3):301-5.
Conflict of Interest
None of the authors have anything to declare.
Financial Support
None
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Milone, M., Di Minno, M.N.D., Bifulco, G. et al. Diagnostic Value of Abdominal Free Air Detection on a Plain Chest Radiograph in the Early Postoperative Period: a Prospective Study in 648 Consecutive Patients Who Have Undergone Abdominal Surgery. J Gastrointest Surg 17, 1673–1682 (2013). https://doi.org/10.1007/s11605-013-2282-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-013-2282-6